OB 2.01 High Risk Pregnancy - Prenatal Assessment PDF

2.
01
September 5, 2016
HIGH RISK PREGNANCY & PRENATAL ASSESSMENT
Dr. Nenita G. Teh
Department of Obstetrics & Gynecology
TOPIC OUTLINE X. Invasive Prenatal Diagnosis Procedures

I. High Risk Pregnancy a. Amniocentesis
a. High risk factors b. Chorionic villi sampling
- Maternal age c. Cordocentesis (percutaneous umbilical cord sampling
- Maternal height [PUBS])
- Maternal weight d. Fetal tissue biopsy
- Social factors (smoking, drugs, alcohol) e. Preimplantation diagnosis
b. Obstetrical history

c. Medical complications
d. American College of Obstetricians and Gynecologists
(ACOG) HIGH RISK PREGNANCY
II. Clinical Assessment of Fetal Well-‐being • The mother of the fetus has a significantly increased chance of
a. Computation of age of gestation (AOG) morbidity and mortality
- Last menstrual period (LMP) • Major cause of perinatal morbidity or mortality
- Ultrasound
b. Serial measurement of maternal weight High Risk Factors
c. Fundic height measurement 1. MATERNAL AGE
- McDonald’s rule • <17 years old – at risk of developing iron defanemia, severe
- Johnson’s rule preeclampsia
III. Fetal movement monitoring • Nullipara>30 years old – at risk of developing diabetes mellitus
a. Maternal perception (DM)
b. Ultrasound • Multipara>35 years old – at risk of chronic hypertension,
c. Doppler superimposed preeclampsia
d. Electronic fetal heart monitoring
IV. Features of Fetal Heart Rate (FHR)
2. MATERNAL HEIGHT
a. Baseline
• <4’11” is accounted with contracted or small pelvis (42%), high risk
b. FHR variability
for operative delivery (C section)
c. Periodic changes
- Acceleration • Too small for big baby, encourage the patient to be managed and
- Deceleration have the delivery in a hospital
V. Electronic Fetal Monitoring
a. Non-‐stress test (NST) 3. MATERNAL WEIGHT
- Reactive NST • Obesity -‐ more than 20% of the standard weight for height
- Non-‐reactive NST • Prone to development of diabetes, hypertensive disorders,
b. Contraction stress test (CST) respiratory distress syndrome and macrosomic babies
- Oxytocin challenge • macrosomic – large for gestational age (LGA) J
- Nipple stimulation
VI. Fetal Deceleration Patterns 4. SOCIAL FACTORS
a. Early deceleration • Smoking
b. Late deceleration o premature delivery
c. Variable deceleration o smaller infants
VII. Unusual Patterns of FHR o increased prenatal deaths
a. Sinusoidal o spontaneous abortion
b. Saltatory
VIII. Intrapartum Assessment • Drugs
a. Electronic fetal heart monitoring o ketogenic effects
b. Biophysical profile/score (BPP/BPS) o illicit drugs produce intrauterine distress and low birth weight
- Fetal breathing o anti-‐hypertensive drugs (ACE inhibitors) prevent renal
- Fetal movement agenesis, thus no fetal urine output, anhydroamnion
- Fetal tone
- Amniotic fluid index (AFI) • Alcohol
- Non-‐stress test (NST) o fetal alcohol syndrome
c. Ultrasound o microcephaly
- Transvaginal probe o craniofacial disease
- Transabdominal probe o slant eyes
d. Doppler velocimetry o low IQ
IX. Prenatal Diagnosis o mental retardation
a. Screening tests
- Alpha-‐feto protein (AFP) Obstetrical History
- Triple screening for Trisomy 21 1. High parity
• Beyond 20th week of gestation

1 of 10 [ OB Girls ⏐ Faye, Gabby, Jade, Jelyn, Vien ]

High Risk Pregnancy & Prenatal Assessment

• Incidence of certain obstetrical complications (postpartum Fundic Height Measurement
hemorrhage, uterine rupture) • Measured from the symphysis pubis up to the fundus of the uterus
• Fundic height in cm approximates AOG (20-‐34 weeks) for
2. History of previous malformed fetus, neural tube defects Caucasians only
(ancephalopathy), cleft palate
MCDONALD’S RULE (AOG computation)
3. History of premature rupture of membrane (PRM) 𝐴𝑔𝑒 (𝑤𝑒𝑒𝑘𝑠) = 𝑓𝑢𝑛𝑑𝑖𝑐 ℎ𝑒𝑖𝑔ℎ𝑡 𝑐𝑚 𝑥 8/7
• If presenting part is not fixed in the pelvis, the possibility of collapse
of the cord and subsequent compression is greatly increased JOHNSON’S RULE (estimated fetal weight)
𝐸𝐹𝑊 (𝑘𝑔) = 𝐹𝐻 – 11 𝑥 0.155
4. Preterm labor
5. Multiple gestations – may lead to abruptio placenta • FH is only a rough guide.
6. History of multiple pregnancies with multiple malformed babies • This measurement may be altered by the following causes:
7. Existence of chromosome abnormality o myoma (↑)
8. History of Down’s syndrome o hydramnios/oligohydramnios (↑/↓)
o multiple gestation (↑)
Medical Complications o IUGR and fetal death (↓)
1. Infection
• UTI, sepsis • 12 weeks à at the level of symphysis pubis
• 16 weeks à between symphysis pubis and umbilicus
2. Hypertensive disorder • 20 weeks à at the level of umbilicus
• Intrauterine growth retardation (IUGR)

3. Diabetes mellitus
FETAL MOVEMENT MONITORING
• High risk for RDS • Quickening = multi @ 16-‐18 weeks; primi @ 18-‐20weeks
• Macrosomia (bigger chest circumference than head circumference) • 7 weeks AOG: passive unstimulated fetal activity
• 20-‐30 weeks AOG: organized body movements
4. Connective tissue disorder • 23 minutes: minimum duration of inactive state of fetus (sleep)
• SLE
• IUGR FETAL BEHAVIORAL STATES
1. STATE 1F – quiescent state (quiet sleep), w/ narrow
• Preterm labor
oscillatory bandwidth of the FHR

2. STATE 2F – includes frequent gross body movements,
American College of Obstetricians and Gynecologists (ACOG)
continuous eye movements, and wider oscillation of FHR;
• Goal of antepartum surveillance is to prevent fetal death
analogous to REM or active sleep in neonates

3. STATE 3F – includes continuous eye movements in the
ACOG 2002
absence of body movements and no accelerations of the HR.
• Purpose: Identification of the fetus at high risk for death or serious
4. STATE 4F – state of vigorous body movements with
morbidity and the delivery of the patient by the safest route as to
continuous eye movements and FHR accelerations;
prevent a less optimal outcome
corresponds to the awake state in infants

• Fetuses spend most time in states 1F and 2F (75% at 38 weeks)
CLINICAL ASSESSMENT OF FETAL WELL-‐BEING • Comparison of 1F and 2F:
Computation of the Age of Gestation (AOG) o 1F has increased bladder volume
1. Last menstrual period (LMP) o 2F has increased FHR baseline bandwidth, diminished bladder
• Alam niyo na ‘to J volume due to fetal voiding and decreased urine production
• If this cannot be recalled or if menstrual cycle is irregular, request (represents reduced renal blood flow during active sleep)
for transabdominal ultrasound (UTZ) as early as possible • Fetal sleep cyclicity – independent of maternal sleep – awake
states; vary from 20 – 75 minutes
2. Ultrasound • Mean length of inactive time – 23 minutes
• Accuracy (aging error):
o 1st trimester UTZ – error is +/-‐ 3-‐5 days Maternal Perception
o 2nd trimester UTZ – error is +/-‐ 1 week • Count to 10 technique
o 3rd trimester UTZ – error +/-‐ 2 weeks • >10 movements/day -‐> good sign

Serial Measurement of Maternal Weight Ultrasound
• 25 lbs (11.4 kg) – average weight gain
• 1 lb/week gain – 20 weeks onwards Doppler
• Weight gain is not expected during the first 12 weeks due to
episodes of nausea and vomiting Electrical Fetal Heart Monitoring
• Semi-‐Fowlers position -‐ position of the mother as the transducer is
EXCESSIVE WEIGHT GAIN DECREASED WEIGHT GAIN placed over the abdomen to record FHR
• Edema • One transducer is placed at the uterine fundus, the other transducer
• IUGR is placed where the fetal heart sounds can be heard
• Preeclampsia
• IUFD (intrauterine fetal death) • FH tracing is interpreted
• Diabetic
• ↓ fluid (premature rupture of • Button is pressed every time the baby moves
• Multiple gestation
membrane [PRM]) • Increase HR with movements
• Polyhydramnios
• Oligohydramnios • Neuronal and hormonal factors:
• Macrosomic baby
• Fetal death 1. Sympathetic -‐ ↑HR
• Wrong/inaccurate AOG
2. Parasympathetic -‐ ↓HR
3. Changes in BP (baroreceptors) can ↑ or ↓HR


4. Cerebral cortical and hypothalamic activity through medullary • Result: reactive or non-‐reactive
5. Integrative centers
6. Chemoreceptors: PaO2 and PaCO2
Result

1. Reactive NST
FEATURES OF FHR • Defined as ≥2 accelerations of FHR that peak at ≥15 bpm, that last
Systematic Approach in the Interpretation of FHR Tracing (full ≥15 seconds within 20 minutes of observation
qualitative and quantitative description)

• Baseline fetal heart rate
• HR variability Mentioned by Dr. Teh:
• Presence of acceleration • 15-‐15 ang magic number sa acceleration
• Periodic changes • If there is no acceleration, extend the observation to ≥40 minutes
o Do some stimulation to wake up the baby before conclusion
Baseline of NST (reactive or non-‐reactive)
• Normal FHR: 120-‐160 bpm [in practice, 110-‐160bpm is acceptable] o ≥40 min tracing for fetal sleep cycles before concluding
1. Bradycardia (<120) = initial response to hypoxemia insufficient reactivity (2B 2018)
2. Tachycardia (>160) = in response to prolonged hypoxemia, • For premature babies (<32 weeks): 10 beats lasting 10 seconds
catecholamines, sympathetic activity lang, reactive na si baby. (Mas mababa ang standard)
• Lower FHR in term than in preterm = PS tone
From 2B 2018:
OTHER FACTORS: NICHHO (1997) definition
• Maternal fever – febrile and expect tachycardia • Defined acceleration based on AOG
• Infection o ≥32 weeks AOG: acceleration of ≥15 bpm for ≥15 seconds
• Medications like terbutaline (maternal tachycardia), atropine within 20 minutes observation
• Tachyarrhythmias o ≤32 weeks AOG: acceleration is ≥10 bpm for ≥10 seconds
within 20 minutes observation
FHR Variability
• Instantaneous and over long periods
• Reflects normal intact pathways
• Predicts early neonatal health (APGAR >7 at 5 minutes)
• Up and down oscillation of ECG
• Decreases with:
1. Hypoxia
2. Sleep
3. Neuro defects
4. CNS depressants

SHORT TERM VARIABILITY (beat-‐to-‐beat contraction)
• Difference between 2 or 3 adjacent heartbeat—best seen with an
EKG than with Doppler
• Results from the vagal tone on FHR, abolished by maternal atropine
• Lost with severe hypoxemia

LONG TERM VARIABILITY Figure 1. Reactive nonstress test. In the upper panel, notice the increase of FHR by
• Rough sine waves: 3-‐6x a minute more than 15 bpm for longer than 15 seconds following fetal movements, which are
• Variation > 6 bpm indicated by the vertical marks (lower panel).

Periodic Agents 2. Non-‐reactive NST
1. ACCELERATION • No increase HR
• Response to fetal movements • Uterine relaxed
• Signals fetal health From 2B 2018:
• Physiology of FHR acceleration:
• +(-‐) CST + Reactive NST = highly predictive of intrauterine survival
• An indication of fetal autonomic function
x 1 week
• Acidosis will temporarily accelerate in response to fetal movement
• Meconium aspiration

o Most common
2. DECELERATION
o Associated with umbilical cord abnormality
• Decreases fetal heart rate by at least 15bpm in 15 secs
• Intrauterine infection
• 3 patterns: early, late, variable
• Abnormal cord position

• Malformations
ELECTRONIC FETAL MONITORING • Placental abruption
• Use of electronic fetal monitor for antepartum surveillance

Non-‐Stress Test (NST)
• Test for acceleration in response to fetal movement
o Test of fetal condition
• Done when the patient is not in labor
o Absence of uterine contraction
• FHR accelerates in response to fetal movement
o Sign of fetal health


From Williams, 24e:
• Uniform repetitive late fetal heart decelerations = uteroplacental
insufficiency
• Late decelerations following 50% or more of contractions (even if
frequency is <3 in 10 minutes)

2. Negative
§ No deceleration
§ Good
§ Dr. Teh: “ Negative = Baby Okay = Good”

3. Suspicious
From Williams, 24e:

Figure 2. Nonreactive NST (left side of tracing) followed by CST showing mild, late • Intermittent late decelerations or significant variable
decelerations (right side of tracing). Cesarean delivery was performed, and the decelerations
severely academic fetus could not be resuscitated.
4. Hyperstimulation
Contraction Stress Test (CST) • Excessive UC that is:
• There is stress in the form of uterine contraction o every 2 mins or more (Dr. Teh)
• Every time the uterus contracts, it occludes the blood vessel → o or lasting >90 secs (2B 2018)
↓blood flow to the fetal circulation o or hypertonus uterus (2B 2018)
o healthy baby will have adequate oxygen reserve to cope with
the stress despite the small decrease in blood flow → no From Williams, 24e:
corresponding decrease in the heart rate • Fetal heart rate decelerations that occur in the presence of
• Test of utero-‐placental function contractions more frequent than every 2 mins or lasting longer
• Only done during term pregnancy than 90 secs
o if tested in preterm patients, early delivery might ensue
(preterm baby) 5. Unsatisfactory
From Williams, 24e:
From 2B 2018: • <3 contractions in 10 minutes or an uninterpretable tracing
• Test for deceleration
• ≥3 spontaneous contractions of 40 secs or longer present in 10
minutes, no uterine stimulation necessary (Williams, 24e)
FHR DECELERATION PATTERNS
• Normal result: uterine contraction of <3x, <40 seconds in 10 1. Early Deceleration
minutes • Secondary to head compression (head is pressed onto the pelvic
• Evaluate reaction FHR to contractions induced either by nipple floor upon pushing -‐ pressure on the fetal skull)
stimulation (15 seconds each nipple) or oxytocin administration • Happens during second stage of labor
o 2nd stage of labor – from full cervical dilatation to delivery of

the baby
• If the patient does not have any contraction, then you can do: o 1st stage of labor – from the start of regular uterine
o Oxytocin Challenge contractions to full cervical dilatation
§ diffuse oxytocin through the IV fluid to cause the uterus • Occurs and coincides with uterine contractions
to contract • ↑contraction = ↓heart beat
o Nipple Stimulation • Lowest point of deceleration coincides with the peak of uterine
§ when oxytocin is contraindicated (in multiparous contractions
patients)

§ if you don’t want to admit the patient (just check the
condition of the baby) From 2B 2018:
§ use of endogenous source of oxytocin (2B 2018)
§ rub the nipple to release oxytocin
§ for them to enjoy the experience, lagyan natin ng music…
*tang-‐tang-‐tang-‐tang-‐tang*
• Result: positive, negative, suspicious, hyperstimulation,
unsatisfactory

Result
1. Positive
• CST with deceleration

• Dr. Teh: “Positive = Pangit = Pathologic”

2. Late Deceleration
From 2B 2018:
• Pathologic
• (+) deceleration ≥2x • Connotes uteroplacental insufficiency
• Decreased heart beat in 15 bpm, ≥15 secs o decreased oxygen flow to the baby
• Pathologic, should include CS delivery • Causes:
o uterine hyperactivity
o maternal hypotension


§ no forward flow from the mother to the fetal
circulation → ↓fetal oxygen transfer → hypoxia →
cardiac depression → vagus nerve activation →
↓FHR
• Placental dysfunction
o premature separation
o ruptured placenta
o placental infarcts
o can also lead to ↓oxygen transfer → anaerobic metabolism →
lactic acid accumulation → fetal acidosis → fetal death
• Lowest point of deceleration is after peak of contraction due to
uteroplacental insufficiency
• Due to hypoxemia or myocardial deceleration

From 2B 2018:
• Smooth and repetitive: occurs with each contraction
• Begins 10-‐30 secs before and ends 10-‐30 secs contraction
• Dr. Teh: late deceleration needs expedite delivery (CS), while early
deceleration does not

UNUSUAL PATTERNS OF FHR
Sinusoidal
• Regular, smooth, wave-‐like with absent short-‐term variability
(SAW-‐TOOTH appearance)
• Indicates fetal anemia
• Secondary to use of opiods
• Dr. Teh: “Parang equal-‐equal”

Saltatory
• Swings in variability: >25bpm = HYPOXIA
• Dr. Teh: HIGH in VARIABILITY

3. Variable Deceleration
• Decelerations before, during or after the contraction
• Viable
• Secondary to cord compression: transitory umbilical cord
compression
o every time the uterus contracts, the cord is compressed
between the uterine wall and the body of the baby
• Not as pathologic as late deceleration
o can still be delivered vaginally Figure 3. Sinusoidal FHR
• Happens in (2B 2018)
o cord coil
o oligohydramnios
o premature rupture of membranes
o ruptured bag of water (BOW)
• Shape of deceleration can be a W or a V form
• Try to change the maternal position or hydrate first (2B 2018)
o this may relieve the coiling or compression respectively
o if no change is observed, you can do CS

Figure 4. Saltatory FHR

• Dr. Teh: “Because of the presence of FHR, there is an increase in
caesarean delivery kasi konting decelerations lang, may fear na baka
madistress yung baby.
• “Ngayon, di na halos Category 1, 2, or 3 but (+) (-‐) or suspicious na
à continuous studies of FHR, tracings”
• “This can be an unreliable method.”



INTRAPARTUM ASSESSMENT Fetal breathing ≥ 1 episode of rhythmic < 30 sec of breathing
Electronic Fetal Heart Monitoring breathing lasting ≥ 30
sec in 30 mins
• Aim: To decrease the incidence of cerebral palsy (1960s)
in 30 mins
• Even with the International Electronic FHR Monitoring, the
incidence is still the same because most of the CP can occur even Fetal movement ≥ 3 discrete body/ limb ≤ 2 movements
before labour. movements
• Management: in 30 mins in 30 mins
o abnormal FHR patterns when the mother is lying supine: place
her to left lateral position Fetal tone ≥ 1 episode of extension No movements
o excessive oxytocin effusion leading to hyperstimulation or of a fetal extremity with or no
tachysystole: discontinue oxytocin or administer return to flexion, extension/flexion
subcutaneous terbutaline 0.25 mg (to relax the uterus and or opening/closing of
relieve of excessive contraction) hand

Biophysical Profile/Score (BPP/BPS)
• Uses ultrasound
AFI Single vertical pocket Largest single
• Usually uses Vibroacoustic NST and AFI
> 2 cm vertical pocket
• Fetal monitor
≤ 2 cm
• Exam time = 30-‐60 minutes
• 10/10 is the perfect score; each parameter is given a score of 2
points
From 2B 2018:
Fetal Breathing • Dr. Teh: Terbutaline ginagamit for asthma, as tocolytic -‐ pang
control ng uterine contraction
• ≥ 1 episode of rhythmic breathing ≥ 30 secs for 30 mins
• Normal FHR and uterine hypercontraction (not secondary to
• Paradoxical chest wall breathing movement:
oxytocin infusion): tocolysis (delaying or inhibition of labor)
o during inspiration, chest wall collapses and abdomen
• Suspected or confirmed acute fetal compromise: delivery
protrudes
should be accomplished as soon as possible
o coughing to clear amniotic fluid debris causes paradoxical
movement
• Types: Limitations of Fetal Heart Monitoring
o Gasps = with frequency of 1-‐4mins 1. Operative delivery
o Irregular bursts of breathing = rate of 240cycles/min 2. Poor intra-‐ and inter-‐ observer agreement at high false (+)
• Factors affecting RR: results
o labor 3. Non-‐ambulation
o hypoglycemia 4. False (+) results
o sound stimuli 5. Unreliability of relationship of FHR changes to fetal well-‐being
o cigarette smoking 6. Continuous presence of nurse or physician
o amniocentesis 7. Maintaining FHR records as legal document
o AOG
o ↓fetal RR w/ ↑resp. vol. (33-‐36 wks) -‐> lung maturation BPP score Interpretation Management

10
Fetal Movements
8/10, NORMAL non-‐ No fetal indication
• ≥ 3 discrete body or limb movement within 30 mins asphyxiated fetus for intervention
Normal fluid 8/8

Fetal Tone
Chronic FETAL
• ≥ 1 extension to flexion of fetal extremity (muscle tone) 8/10
ASPHYXIA (FA) DELIVER
Decreased
suspected
Amniotic Fluid Index (AFI)
If amnionic fluid
• Measures the amount of fluid in the uterus vol abnormal,
• A check for CHRONIC HYPOXIA deliver
• Dr. Teh: Since the amniotic fluid is dependent on uterine or fetal urine
which is then dependent on the blood flow to the kidneys, there will be If normal fluid at
decreased fetal urine (oligohydramnios). 6 Possible FA >36 wks w/
• 5-‐24 cm: NORMAL favorable cervix,
• If < 5: oligohydroamnios deliver
• If > 24: polyhydroamnios
If repeated test
Non-‐Stress Test (NST) score < 6, deliver
• Normal: Reactive NST Repeat testing that
• A check for ACUTE HYPOXIA 4 Probable FA same day; if BPP <
6, deliver
COMPONENT SCORE 2 SCORE 0 0 -‐ 2 Almost certain FA DELIVER
NST ≥ 2 accel of ≥ 15 bpm for 0–1 accel in 20–40
≥ 15 sec in 20-‐40 mins mins Ultrasound (UTZ)
• Discovered in 1958 by Sir Ian Donald


• High frequency sound waves more than 20,000 cycles/sec (20 kHtz) o vaginal bleeding
(Submarine) o uterus retention
• Produces sound waves that reflect image structures 6. Dating or aging (most reliable date at ± 3 days error)
• TRANSDUCER (piezoelectric material) emits pulse sound waves 7. Evaluation of uterus and adnexae (appendage of an organ)
that passes thru the layer of tissues o detection of myoma and ovarian cyst
o Dr. Teh: Pinakamahal na part ng machine (costs half ng 8. Measure crown-‐rump length (CRL) – crown of the head to the sacral
machine: around Php 500,000) area (ave: 36 cm)
• Piezoelectric crystals convert electrical energy to mechanical UTZ
waves Measure Crown Rump Length (CRL)
• The interface between the densities of different tissues densities Trimester Accuracy
encountered will give different reflections (some energy is reflected
1st 3-‐5 days error
back to transducer).
• Bone: whitE (Echogenic) 2nd ± 1 week error
o The denser the tissue, mas echogenic = maputi 3rd ± 2 weeks error
• Fluid: blAck (Anechoic)
9. Scan for possible aneuploidy by measuring nuchal translucency
(Normal: <3 mm)
o Nuchal Translucency -‐ collection of fluid under the skin at the
back of fetal neck
o If wide, high risk for TRIPLOIDY

Figure 5. Obstetric ultrasound image

TRANSVAGINAL PROBE TRANSABDOMINAL Figure 6. Crown-‐rump Length (L) and Nuchal Translucency (R)
5-‐7 MHz 3 MHz
↓ wavelength ↑ wavelength Indications for 2nd – 3rd Trimester Ultrasound
Higher Frequency Low Frequency 1. Detailed congenital anomaly scanning (usually at 18-‐24 weeks)
Better image resolution Better tissue penetration 2. Fetal viability and number
3. Fetal presentation – cephalic or breech?
1st trimester (because it can’t see 2nd and 3rd trimester 4. Placental localization
the big structures in 2nd and 3rd o Dr. Teh: Before 32 weeks, pwede pang mag ‘placental migration’
trimester) (due to increase uterine size)
Small masses Bigger masses/babies o So dapat after 32 weeks, para may ‘placental previa’ wherein
Empty bladder Full bladder (to elevate uterus) the placenta is very low near the cervix
Direct contact with uterine cervix 5. Aging (2nd trimester ± 1 week; trimester ± 2 weeks)
6. Evaluation of fetal growth – fast or slow?
Also used for trans-‐rectal 7. Assessment of fetal well-‐being (HR)
8. Estimation of fetal weight (during last trimester)
9. Check for presence of cleft lip (3D UTZ – clearer)
From 2B 2018:
• Dr. Teh: Weight, presentation, and placental localization From 2B 2018:
(important in 3rd trimester) • Virgin – transrectal ultrasound
• Nuchal Translucency: ≤9mm-‐normal; ≥9mm -‐ Trisomy 21 • With sexual contact – transvaginal probe

ULTRASOUND PURPOSE Doppler Velocimetry
3D UTZ To detect presence of cleft lip and • Usually requested for babies with IUGR
palate, gender, and face o decreased size
o cases of HPN, DM, pre-‐eclampsia
4D UTZ Same as 3D but live (moving) • Assess blood flow from the mother to the baby (by characterizing
5D UTZ Blood vessels can already be downstream impedance)
seen; transparent • Umbilical Artery
Both 3D and 4D are applicable on the 28th-‐32nd weeks of gestation o measure for Systolic/Diastolic Ratio > 90th % for AOG
o presence of:
§ absent end-‐diastolic blood flow
Indications for 1st Trimester Ultrasound § reverse end-‐diastolic blood flow
1. Establishment of intrauterine pregnancy (IUP) • Check for different characteristic waveforms of different blood
2. Rule out ectopic pregnancy vessels (umbilical artery, fetal cerebral artery, uterine artery, etc.)
3. Detection of embryonic/fetal life
4. Identification of number of fetuses
o the best time because it is not prone to error
o it can be seen if there are 2 or 3 sacs
5. Evaluation of complicated early pregnancy (incomplete abortion)


o number of fetuses
o AOG

Normal value: 0.4-‐2.5

AFP < 0.4 MOM* AFP > 2.5 MOM*
• Down’s syndrome • ↑ risk for neural tube defects
• Molar pregnancy (anencephaly, spina bifida)
• IUFD • ventral wall defects, anomalies
Figure 7. Doppler assessment of umbilical artery and vein (with color)
• Increased maternal weight • Dr. Teh: omphalocele (base of cord
• During DIASTOLE, there is more blood flow to the baby • Overestimation of AOG insertion) vs. gastrokinesis (defect
o Sound source: UTZ transducer lateral to cord insertion, mas
o Moving target: RBC flowing thru circulation nabubuhay)
o Reflected sound wave observed by UTZ transducer • Sensitivity : 90% PP = 2-‐6%
• In the presence of HYPOXIA, the tendency is that the baby will *MOM = multiples of media
conserve the oxygen and distribute it to more vital organs (brain,
lungs, heart) [brain-‐sparing reflex] and there will be decreased Triple Screening for Trisomy 21 (Down Syndrome)
blood flow to other organs (liver, muscles, and kidneys) for survival.
• Identifies 60% of all trisomy 21 in < 35 y/o and 75% in > 35 y/o
• First, there will be an initial decrease on diastolic blood flow in the
(primipara)
umbilical artery.
• High false (+) rate
• Pag sumobra ang hypoxemia, mawawalan lalo ng diastolic blood

flow. Kapag masyado ng nagcompensate ang baby
Includes: hCG, estriol, unconjugated, AFP
(decompensation), there will be a REVERSE FLOW (Bumabaliktad

na: Left Atrium à Foramen Ovale à Right atrium à IVC)
• Reversed End-‐Diastolic Blood Flow: sign of impending fetal death INVASIVE PRENATAL DIAGNOSIS PROCEDURES
L Amniocentesis
• The opposite happens to the brain or the fetal cerebral artery. If • Done between 15-‐20 weeks AOG
the EDV is high here, it means that there is little oxygen in the fetal o highest amount of amniotic fluid
circulation. • Use gauge 22 spinal needle, which is inserted into the amniotic sac
• If this ‘high’ suddenly goes low, it’s already decompensated which while avoiding the placenta, umbilical cord and fetus
will then lead to fetal death. L • Initial 1-‐2 mL aspirate is discarded or used for amniotic fluid AFP
testing because it may be contaminated with maternal cells
• Approximately 20 mL is collected for fetal karyotyping
PRENATAL DIAGNOSIS
• Ultrasound guided to avoid needle injuries to the fetus
• Identifying structural and functional abnormalities in the
developing fetus Complications:
• Conditions that may necessitate Genetic Counseling: • There is transient vaginal spotting or amniotic fluid (AF) leakage in
o birth of a malformed child 1-‐2% pregnant women
o inheritable disorders • Chorioamnionitis
o advanced maternal age
• Fetal loss rate < 0.5%
o Common ang Down syndrome
• If done early, it is performed between 11-‐14 weeks AOG
o exposure to teratogens
o less can be withdrawn (usually 1mL for each week of
o consanguineous marriage
gestation), UTZ guided
o recessive trait lalabas, magiging homozygous
o more complications
o birth defects in the family
• Early amniocentesis appears to result in significantly higher rates of
o abnormal ultrasound findings
post-‐procedural pregnancy loss and other complications than
o habitual abortions and stillbirths
traditional amniocentesis

Non-‐ Invasive Screening Test
Disadvantages:
Alpha-‐Feto Protein
• Lack of membrane fusion to uterine wall makes puncture to sac
• Glycoprotein synthesized by the fetal yolk sac during early difficult
gestation and later replaced by GIT and liver, then secreted to • Less fluid can be drawn at 15-‐20 weeks (11-‐14wks)
the fetal serum, fetal urine, and AFV; then diffuses across • Risk for Talipes deformity [clubbing of feet due to decreased in
placental membrane amniotic fluid
• Concentration increased steadily in both fetal serum AFP until 13
weeks (3 mg/ml) and then decreases rapidly From Williams, 24e:
• Increased AFP in maternal serum after 12 weeks
• Most common procedure used to diagnose fetal aneuploidy and
• Also increased if there is a break in fetal integument (uncovered
other genetic conditions
organ)
• Amniocytes must be cultured before fetal karyotype can be
• Testing done at 15-‐22 weeks
assessed

• The time needed for karyotyping is 7 to 10 days
MATERNAL AFP SCREENING
• Amniotic fluid occasionally may be removed in large amounts
• Done between 15-‐22 weeks
therapeutically to relieve symptomatic hydramnios
• Factors influencing results:

o maternal age
Technique:
o maternal weight (decreased in obese)
• aseptic technique, under direct sonographic guidance, using a
o maternal race (increased in blacks)

o diabetic status (decreased in diabetics)


• 20-‐ to 22-‐gauge spinal needle available earlier in pregnancy, allowing safer pregnancy
• A standard spinal needle is approximately 9 cm long, and termination, if desired
depending on the patient habitus, a longer needle may be required • A full karyotype is available in 7 to 10 days, and some
• The needle is directed into a clear pocket of amniotic fluid, while laboratories provide preliminary results within 48 hours
avoiding the fetus and umbilical cord and ideally without
traversing the placenta
Technique:
• Efforts are made to puncture the chorioamnion rather than to
“tent” it away from the underlying uterine wall • Chorionic villi may be obtained transcervically or
• Because the initial 1 to 2 mL of fluid aspirate may be transabdominally using aseptic technique
contaminated with maternal cells, it is generally discarded • Both approaches are considered equally safe and effective
• Approximately 20 mL of fluid is then collected for fetal • Transcervical villus sampling is performed using a specifically
chromosomal analysis before removing the needle designed catheter made from flexible polyethylene that contains a
• Sonography is used to observe the uterine puncture site for blunt-‐tipped, malleable stylet
bleeding, and fetal cardiac motion is documented at the end of the • Transabdominal sampling is performed using an 18-‐ or 20-‐gauge
procedure spinal needle. With either technique, transabdominal sonography
• If the patient is Rh D-‐negative and unsensitized, anti-‐D immune is used to guide the catheter or needle into the early placenta –
globulin is administered following the procedure chorion frondosum, followed by aspiration of villi into a syrige
• Amniotic fluid should be clear and colorless or pale yellow containing tissue culture media
• Fetal cardiac motion is documented following the procedure
• Blood-‐tinged fluid is more frequent if there is transplacental
passage of the needle; however, it generally clears with continued • Relative contraindications include vaginal bleeding or spotting,
aspiration active genital tract infection, extreme uterine ante-‐ or
• Dark brown or greenish fluid may represent a past episode of retroflexion, or body habitus precluding adequate
visualization
intraamnionic bleeding
• If the patient is Rh D-‐negative and unsensitized, anti-‐D immune
Amniocentesis in Multifetal Pregnancy globulin is administered
• For twin gestations, a small quantity of dilute indigo carmine
dye is often injected before removing the needle from the first Cordocentesis or Percutaneous Umbilical Cord Sampling (PUBS)
sac • Currently performed primarily for the assessment and treatment
• This can be accomplished using 2 mL of a solution in which 1 mL of of confirmed red cell or platelet alloimmunization and for the
indigo carmine has been diluted in 10 mL of sterile saline analysis of non-‐immune hydropsis
• When the second sac is entered, the return of clear amniotic fluid • Getting blood from umbilical cord -‐ needle inserted usually
verifies needle positioning within the second sac at or near its placental origin
• Methylene blue dye is contraindicated because it has been • Needle (gauge 22) is placed into the mother’s abdomen and the
associated with jejunal atresia and neonatal methemoglobinemia amniotic cavity and then guided into the umbilical artery or vein,
UTZ guided

Chorionic Villus Sampling (CVS) Indications
• Evaluation of fetal cord abnormality
• Done between 9-‐11 weeks AOG (Williams: 10-‐13 weeks AOG)
• Severe IUGR
• Needle inserted in the area of the placenta
• Congenital infection
2 routes: • Thrombocytopenia
1. TRANSCERVICAL APPROACH • Hydropsis fetalis (abnormal accumulation of fluid in 2 or more
• 1st trimester: needle is inserted at the cul-‐de-‐sac (space fetal compartments)
immediately behind the vagina) • Twin-‐twin transfusion syndrome
• Relative contraindications: • Genetic diseases
o vaginal bleeding or spotting From Williams, 24e:
o extreme ante or retroverted uterus • Fetal blood sampling is also performed for assessment and
o patient body habitus treatment of platelet alloimmunization and for fetal karyotype
o active cervico-‐vaginal infection determination, particularly in cases of mosaicism identified
following amniocentesis or CVS
2. TRANSABDOMINAL APPROACH • Fetal blood karyotyping can be accomplished within 24 to 48
• Patient is asked to drink 1L of water to raise the uterus into the hours
abdominal cavity • It is significantly quicker than the 7-‐ to 10-‐day turnaround time
with amniocentesis or CVS
Advantage of CVS over amniocentesis • Although fetal blood can be analyzed for virtually any test
• Results are available earlier in pregnancy which lessens parental performed on neonatal blood, improvements in tests available
anxiety when results are normal with amniocentesis and CVS have eliminated the need for fetal
• It also allows earlier and safer methods of pregnancy venipuncture in most cases
termination when the results are abnormal
From Williams, 24e: Technique:
• Biopsy of chorionic villi is generally performed between 10 and • Under direct sonographic guidance, using aseptic technique,
13 weeks’ gestation the operator introduces a 22-‐ or 23-‐gauge spinal needle into
• Although most procedures are performed to assess fetal the umbilical vein, and blood is slowly withdrawn into a
karyotype, numerous specialized genetic tests can also be heparinized syringe
performed by chorionic villus sampling (CVS) • Fetal blood sampling is often performed near the placental cord
• Very few analyses specifically require either amniotic fluid or insertion site, where it may be easier to enter the cord if the
placental tissue placenta is anterior
• The primary advantage of villus biopsy is that results are • Alternatively, a free loop of cord may be punctured



• A local anesthetic may be administered
• Arterial puncture is avoided because it may result in
vasospasm and fetal bradycardia

Fetal Tissue Biopsy
• Dx of muscular dystrophy and mitochondrial myopathy
• Skin biopsy is used to diagnose epidermolysis bullosa

Preimplantation Diagnosis
• For in-‐vitro fertilizaton
• Blastomere biopsy (6-‐10 cell stage)à thru a hole made in zona
pellucida
• In polar analysis, majority of polar bodies are in Metaphase, thus
the chromosomes are suitable for Fluorescence In situ
Hybridization (FISH)
• Allows selection of only the healthy embryo

INDICATIONS
• Diagnosis of single gene defects such as cystic fibrosis and sickle
cell anemia
• Identification of aneuploidy
• Sex determination of X-‐linked diseases

PRE-‐LEC QUIZ
1. If your patient has an irregular menstrual cycle, what would be your
basis for the AOG?
2. What is the formula used to estimate the fetal weight using the
fundic height?
3. Define what a reactive non-‐stress test is.
4. Give at least two components of a biophysical profile.
5.
6. Deceleration secondary to head compression in a CST
7. Give at least one indication for a first trimester ultrasound.
8. When is the best time in weeks to do an amniocentesis?
9. Fetal condition with an abnormally low alpha-‐feto protein
10. When is the best time in weeks to do a chorionic villi sampling?

Answers:
1. ultrasound
2. Johnson’s rule
3. ≥2 accelerations of FHR peaking at 15 bpm, each lasting ≥15 seconds
within 20 minutes
4. fetal breathing, fetal movements, fetal tone, amniotic fluid index (AFI), non-‐
stress test (NST), modified BPP
5.
6. early deceleration
7. establishment of intrauterine pregnancy (IUP), rule out ectopic pregnancy,
detection of embryonic/fetal life, identification of number of fetuses,
evaluation of complicated early pregnancy, dating or aging, evaluation of
uterus and adnexae
8. 15-‐20 weeks AOG
9. Down’s syndrome, IUFD
10. 9-‐11 weeks AOG

TRANSERS’ MESSAGE!!! J

New shifting na! Move on na mula sa nakaraang shifting and game
face on na ulit for moreee challenges! >:)

“Doesn’t matter how tough we are. Trauma always leaves a scar. It follows
us home, it changes our lives, Trauma messes everybody up, but maybe
that’s the point: All the pain and the fear and the crap. Maybe going
through all of that is what keeps us moving forward, it’s what pushes us.
Maybe we have to get a little messed up, before we can step up.” –Alex
Karev, Grey’s Anatomy S05E18 Elevator Love Letter

Step up, 2019! #2019kakayanin #100percentpromotion J

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TOPIC OUTLINE X. Invasive Prenatal Diagnosis Procedures

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